1. Coronary heart disease and stroke: preventing vascular disease
Coronary heart disease (CHD) is caused by the progressive narrowing or by the blockage of
one or more of the small arteries that supply the muscle of the heart. As less blood gets
through these arteries the oxygen supply to the heart muscle is reduced. This causes pain on
exertion (angina) and reduces the amount of work that the heart can do. If the narrowing gets
too great or there is a sudden blockage caused by a small blood clot the blood supply to a
portion of the heart is stopped completely. This is a ‘heart attack’ and, together with stroke, is
still the most common cause of death in this country and in Barnet. For example, since 1993,
the average number of deaths in Barnet, from all causes, has been 2,840 (it has dropped
steadily from 3,130 in 1993 to 2,461 in 2006). The average number of deaths in Barnet each
year from heart attack over this time has been 280 (it has dropped steadily from 326 in 1993 to
202 in 2006).
Figure 1 shows comparative rates and trends in deaths from heart attack in England and
Wales, London and Barnet. Rates are decreasing, but they are lower in Barnet and decreasing
at a slightly higher rate. In part, this is due to a lower average prevalence of smoking in the
borough and an above-average level of affluence.
Figure 1: Age-standardised death rate from heart attack nationally, in London and Barnet
Source: Office for National Statistics
Stroke is caused by either a blockage of one of the blood vessels supplying the brain or, less
commonly, by one of these blood vessels bursting and bleeding. In either event, the blood
supply to a portion of the brain is suddenly stopped. This is a ‘stroke’ (also called a cerebro-
vascular accident or ‘CVA’) and leads to a permanent loss of function of the part of the brain
affected.
Figure 14shows comparative rates and trends in deaths from stroke in England and Wales,
London and Barnet. Like heart attack, rates are decreasing, but they are lower in Barnet and
decreasing at a slightly higher rate.
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2. Figure 2: Age-standardised death rate from stroke nationally, in London and Barnet
These two diseases have similar origins: they are usually caused by progressive damage to the
lining of blood vessels. This damage occurs in many parts of the body but the heart and the
brain are more susceptible to a loss of blood supply than most other organs. CHD and stroke
are often combined into one condition – cardio-vascular disease (CVD) for this reason.
The most common causes of CVD are smoking, high blood pressure, raised blood cholesterol
levels and diabetes. These last three risk factors are much more common amongst people who
are obese. Put another way, the most common cause of death in Barnet is mainly caused by
two things: smoking and obesity. If we wish to reduce the number of people who die each year
from avoidable disease then we need to help people – in various different ways – to stop
smoking and, if they are overweight or obese, to lose weight.
The risk we face
Death rates from CVD have been dropping in recent years both in Barnet and nationally. There
have been two main reasons for this: nationally, the prevalence of smoking has been dropping1
and treatment for both heart attack and stroke (especially for heart attack) is more effective now
than it was.2
However, the ‘obesity epidemic’ and the projected change in Barnet’s population (concerning
Barnet’s impending ‘middle age spread’) mean that we can expect more people to be at risk of
CVD than before. Unless we take active steps to help people to reduce lifestyle risks such as
smoking and obesity, and take active steps to identify more people with established problems
such as raised blood pressure, raised blood cholesterol and diabetes, then this downward trend
in death rates is likely to reverse.
1
In part, the reduction in smoking prevalence is attributable to NHS and other services enabling people to quit.
Smoking cessation in Barnet is discussed in section Error: Reference source not found. In part, the reduction in
smoking prevalence is also due to taxation and smoke-free legislation and to a decreasing social acceptance of
smoking. No one measure will work alone in helping people to quit (and preferably not to start) and it is
necessary for the NHS, local government, employers, landlords and others to continue to discourage smoking as
much as possible and to facilitate people to quit (for example, by actively encouraging people to attend smoking
cessation services during working hours and not to have smoking breaks at work).
2
The Department of Health is looking to the NHS to provide immediate revascularisation services for everyone
who has a heart attack, i.e. passing a small balloon on a catheter through an artery in groin into the affected
blood vessel of the heart and expanding the narrowed area and then ‘splinting’ it with a stent to help keep it
open. This requires specialist facilities and staff and thus, increasingly, people who have heart attacks will not be
take to the nearest hospital but to one with these facilities.
However, reducing deaths from CHD also requires the identification of people with risk factors such as high
blood pressure and raised blood cholesterol and diabetes and managing these conditions aggressively to reduce
risk.
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3. The relationship between diversity and deprivation and CVD
The impact of deprivation on health is shown most starkly in terms of deaths from coronary
heart disease, which, together with stroke, is the most common cause of death. Everyone will
die of something, so we tend to look at ‘premature’ deaths and this is defined as death
occurring under the age of 75 years.
Figure 3 shows the trend in deaths in Barnet from coronary heart disease in recent years. This
has been constructed by ranking superoutput areas in order of deprivation score (see Error:
Reference source not found) and then dividing these into three groups of lowest, middle and
highest deprivation.
Figure 3 clearly shows that, in terms of coronary heart disease, people living in the most
deprived parts of the borough are most likely to die prematurely.
Figure 3: Age-standardised death rates from coronary heart disease in people aged
under 75 years grouped by super-output areas ranked in order of deprivation
Asian people are at higher risk of developing diabetes and consequently have a risk of
developing coronary heart disease that is about 40% higher than amongst the White population
in the UK,i
principally because of the damage that diabetes does to the blood vessels. People
from Black, and especially African-Caribbean, ethnic groups are also at higher risk of stroke,
principally because of a genetic predisposition to developing high blood pressure. However, for
reasons that are not clear, Black people are between 25% and 50% less likely to have coronary
heart disease than the White population in the UK.
Age is also a factor in death from CVD: death from a heart attack or a stroke is more likely to
occur in an older person than a younger one. This may seem obvious, but the important point is
that many people live to an old age before dying of a CVD-related event, as shown in and
Figure 4 and .
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Medium Deprivation SOAsMedium Deprivation SOAs
High Deprivation SOAsHigh Deprivation SOAs
PCT AveragePCT Average

4. Figure 4: The total number of deaths from cardiovascular disease in Barnet over the
four-year period 2004-2007 by age group Source: Office for National Statistics Annual
District Mortality Data
Figure
5: The total number of deaths from stroke in Barnet in 2007 by age group
Source: Office for National Statistics Annual District Mortality Data
Local targets
Figure 6 shows the current death rate in people aged under 75 years in Barnet and the
trajectory for this that has been agreed as a target to achieve. This is especially challenging:
the death rate from this disease cannot be expected to continue to drop until it reaches zero.
However, it is also clear that death rates in the more deprived parts of the borough are higher
than in the more affluent ones and if more effort is made with the people at special risk of CVD
who live in these areas then overall CVD deaths should decrease.
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5. Figure 6: The trajectory for deaths from cardiovascular disease
Key things that need to be done
The key activities required are:
 maintaining the current good performance on smoking cessation and, especially in the more
deprived areas, to try to increase the number of people quitting smoking;
 establishing ways for GP practices and acute and community sector providers to identify
people with obesity and to refer them to specific services to enable them to lose weight
which need to be of two types –
− for people with ‘simple’ obesity and no other established medical problems,
− for people with obesity and co-morbidity, e.g. conditions such as high blood pressure,
raised blood cholesterol, diabetes, as helping these people to lose weight requires careful
monitoring of the treatment they have for their other conditions;
 working with employers to make it easier for their staff to (i) be healthier at work and (ii)
identify any established health risks such as smoking, obesity, high blood pressure and for
these risks to be properly dealt with;
 working with schools to increase opportunities for healthy eating and taking exercise and to
increase understanding amongst younger people of the importance of healthier lifestyles;
 targeting people at special risk of CVD who, for various reasons, do not see themselves at
such risk and encouraging and enabling them to reduce CVD risk factors.

6. i
Department of Health. Coronary Heart Disease National Service Framework. Chapter two: Preventing
coronary heart disease in high risk patients. Department of Health. London. 2000

7. i
Department of Health. Coronary Heart Disease National Service Framework. Chapter two: Preventing
coronary heart disease in high risk patients. Department of Health. London. 2000